Paradoxical Insomnia in the Presence of Mild Obstructive Sleep Apnea: A Case Report Illustrating Diagnostic Complexity and Treatment Challenges

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We present a case of paradoxical insomnia comorbid with mild obstructive sleep apnea (OSA), highlighting diagnostic and therapeutic challenges. A 37-year-old woman presented with severe chronic insomnia, reporting sleeping only “minutes per night,” despite appearing alert and functional. A two-night home sleep test showed normal sleep latency (7 minutes), sleep efficiency (86.6%), and total sleep time (4.5 hours). Mild OSA was noted (AHI = 5 events/hour) but was not considered causative of her distress. Multiple trials of hypnotics, antidepressants, benzodiazepines, and antipsychotics yielded no subjective improvement. The patient maintained a delusional-like conviction of sleeplessness despite objective evidence to the contrary. This case underscores the importance of recognizing paradoxical insomnia, particularly when complaints are disproportionate to objective findings and mild comorbid OSA is present. Management should prioritize cognitive-behavioral therapy for insomnia (CBT-I) and psychoeducation over pharmacologic escalation. Clinicians should communicate objective sleep data with empathy to avoid therapeutic rupture and promote engagement in behavioral interventions. Paradoxical insomnia Sleep-state misperception Obstructive sleep apnea Insomnia Cognitive-behavioral therapy for insomnia Case report Background Insomnia is a common disorder, affecting an estimated 6–33% of the general population [ 1 , 2 ]. A subset of patients presents with paradoxical insomnia (also termed sleep-state misperception), defined by a striking mismatch between subjective complaints of severe sleeplessness and objective evidence of relatively normal sleep duration and architecture [ 3 , 4 ]. Emerging evidence suggests that paradoxical insomnia may involve altered sleep microstructure, hyperarousal, or neurocognitive abnormalities during sleep rather than a quantitative reduction in sleep time [ 5 , 6 ]. Comorbid psychiatric conditions, particularly anxiety and obsessive-compulsive traits, are common and may exacerbate the misperception. The diagnostic picture can be further complicated by comorbid sleep-disordered breathing, such as obstructive sleep apnea (OSA), a condition characterized by repeated episodes of partial or complete upper airway obstruction during sleep, quantified by the Apnea-Hypopnea Index (AHI), which measures the average number of apneas and hypopneas per hour of sleep [ 7 ]. Differentiating paradoxical insomnia from other insomnia subtypes is critical to avoid unnecessary pharmacologic interventions and to direct patients toward evidence-based behavioral treatments. Case Presentation A 37-year-old woman presented with severe, chronic insomnia, persistently reporting sleeping only “minutes per night.” Despite appearing alert and functional, she scored 2 on the Epworth Sleepiness Scale (ESS) [ 8 ] and 28 on the Insomnia Severity Index (ISI) [ 9 ], indicating severe clinical insomnia. A two-night home sleep test revealed normal sleep architecture with mild OSA (Apnea–Hypopnea Index [AHI] = 5 events/hour), objectively confirming over 4.5 hours of sleep. Multiple pharmacological trials, including hypnotics, sedating antidepressants, benzodiazepines, and antipsychotics, provided no subjective improvement (Table 3 ). The patient maintained a fixed belief of sleeplessness despite contrary evidence. The ESS and ISI results are summarized in Table 1 and Table 2 , respectively. Table 1 Epworth Sleepiness Scale Results Situation Score (0–3) Sitting and reading 0 Watching television 0 Sitting inactive in a public place 0 Being a passenger in a car for an hour 1 Lying down to rest in the afternoon 0 Sitting and talking to someone 0 Sitting quietly after lunch 0 Stopped in traffic while driving 1 Total Score 2 Note: A score ≤ 10 is considered normal. Table 2 Insomnia Severity Index Results ISI Item Score (0–4) 1. Severity of sleep onset difficulty 4 2. Severity of sleep maintenance difficulty 4 3. Severity of early morning awakening 4 4. Dissatisfaction with sleep pattern 4 5. Noticeability of impairment 4 6. Worry/Distress about sleep problem 4 7. Interference with daily functioning 4 Total Score 28 Note: Scores 22–28 indicate severe clinical insomnia. Table 3 Summary of Previous Pharmacological Interventions Medication Class Specific Medication & Regimen Duration Reported Outcome Non-Benzodiazepine Hypnotics Zolpidem 10 mg nightly 2 nights No subjective benefit Eszopiclone 2 mg nightly 2 nights No subjective benefit Sedating Antidepressants Trazodone up to 150 mg nightly ~ 3 weeks Minimal change Doxepin 10 mg nightly 2 nights Minimal change Mirtazapine 15 mg nightly ~ 3 weeks No perceived sleep Benzodiazepines Lorazepam 1–2 mg nightly 3 nights No benefit reported Temazepam 15 mg nightly 2 nights No benefit reported Antipsychotics Quetiapine 25–50 mg nightly 2 nights No subjective improvement Olanzapine 5 mg nightly 2 nights No subjective improvement Risperidone 1 mg nightly 1 night No subjective improvement Lurasidone 20 mg nightly 1 night No subjective improvement Other Sedatives Hydroxyzine 50 mg nightly 2 nights No reported sleep Gabapentin 300 mg nightly 2 nights No reported sleep Investigations A two-night home sleep test was performed. The key objective findings and their clinical interpretation are summarized in Table 4 . Table 4 Home Sleep Test Results and Interpretation Parameter Result Interpretation Sleep Latency 7 minutes Normal sleep onset Total Sleep Time 4.49 hours Objectively confirms substantial sleep duration (> 4 hours) Sleep Efficiency 86.6% Good sleep continuity (normal > 85%) Mean SpO₂ 95.9% Normal oxygen saturation Lowest SpO₂ No desaturation below 90% Absence of significant hypoxemia Apnea-Hypopnea Index (AHI) 5.0 events/hour Meets criteria for mild Obstructive Sleep Apnea (OSA) [ 7 ] Supine Sleep 63.7% Indicates positional sleep but not predominantly supine These findings objectively confirmed adequate sleep duration and architecture, with only mild, non-positional OSA present. When presented with the results, the patient expressed profound disbelief, insisting the device was inaccurate and maintaining she had been awake “all night.” Differential Diagnosis The clinical presentation prompted consideration of several diagnostic possibilities. The profound and persistent mismatch between the patient's subjective conviction of near-total sleeplessness and the objective evidence of normal sleep architecture and duration, coupled with refractoriness to multiple classes of sedating medications, was most consistent with a primary diagnosis of paradoxical insomnia. This perceptual disorder was likely exacerbated by anxiety-related hypervigilance and a somatic misperception, where quiet wakefulness or light sleep was misinterpreted as full wakefulness. An obsessive focus on sleep, characterized by intrusive ruminations about not sleeping, was a prominent perpetuating factor. While mild obstructive sleep apnea was objectively present, its severity (AHI = 5) was insufficient to explain the degree of subjective distress or the reported complete lack of sleep, making it a comorbid condition rather than the primary etiology. A somatic delusional disorder was considered but deemed less likely due to the patient's preserved insight in other domains, absence of other psychotic features, and the primary emotional distress centered on the sleep complaint itself rather than a fixed, bizarre somatic belief. Treatment and Outcome Given the failure of pharmacotherapy, treatment shifted to non-pharmacological intervention. A structured Cognitive-Behavioral Therapy for Insomnia (CBT-I) program was recommended, focusing on sleep restriction, stimulus control, cognitive restructuring, and relaxation training. Psychoeducation regarding paradoxical insomnia and the home sleep test results was provided repeatedly. Over six weeks of follow-up, the patient began to reluctantly reframe brief sleep episodes as “light rest,” though her core conviction of being awake most of the night persisted. Due to ongoing distress and limited insight, she was referred to a residential sleep-disorder behavioral program for intensive intervention. Discussion This case illustrates the diagnostic complexity that arises when paradoxical insomnia co-occurs with mild OSA. While the presence of mild OSA can sometimes explain or exacerbate sleep complaints, its clinical profile in this case was incongruent with the patient's extreme report of total sleeplessness. The core pathology aligned more closely with the hypervigilance, somatic focus, and catastrophic misinterpretation characteristic of paradoxical insomnia, as described in the literature [ 3 , 4 ]. This reinforces the principle that comorbid conditions must be carefully evaluated for their causal contribution to the primary complaint. The patient's complete lack of response to multiple drug classes, spanning traditional hypnotics to sedating antipsychotics, is a hallmark of paradoxical insomnia and underscores that it is generally refractory to standard hypnotic pharmacotherapy [ 4 , 10 ]. As medications that increase sleep drive do not correct the underlying perceptual distortion, this case powerfully reinforces the established guideline that first-line management for chronic insomnia, and particularly its paradoxical subtype, should be CBT-I, which directly targets the maladaptive thoughts and behaviors perpetuating the condition [ 4 , 11 ]. A significant clinical challenge encountered was the communication of objective sleep data. For the patient, being told she had "slept several hours" was perceived as invalidating and paradoxically increased her anxiety, a known risk that can lead to therapeutic rupture [ 12 ]. This experience highlights that clinicians must deliver such feedback with profound empathy and within a robust psychoeducational framework, normalizing the phenomenon of sleep-state misperception to foster engagement rather than defensiveness [ 4 , 12 ]. This case underscores several critical clinical lessons. First, paradoxical insomnia should be actively considered when a patient presents with severe subjective complaints that are strikingly disproportionate to objective sleep findings. Second, the presence of a mild comorbid condition such as OSA does not preclude a primary diagnosis of paradoxical insomnia and requires careful, nuanced clinical interpretation to avoid attributing the core complaint to an incidental finding. Third, pharmacotherapy alone is often ineffective for paradoxical insomnia, as medications do not correct the underlying perceptual distortion; therefore, first-line management should center on Cognitive-Behavioral Therapy for Insomnia (CBT-I) and targeted psychoeducation. Finally, communicating objective sleep results to the patient demands sensitivity and must be framed within a supportive therapeutic alliance to avoid invalidating the patient’s experience, which could otherwise lead to disengagement and therapeutic rupture. Conclusions This case report highlights the critical importance of recognizing paradoxical insomnia, a condition defined by a profound subjective-objective sleep discrepancy. Accurate diagnosis is essential to avoid iatrogenic harm from escalating and ineffective pharmacotherapy and to steer patients toward evidence-based behavioral interventions. The co-occurrence of mild OSA adds a layer of diagnostic complexity but does not negate the primary perceptual pathology. The key message is that management must prioritize Cognitive- Behavioral Therapy for Insomnia and careful, empathetic psychoeducation over pharmacological strategies. Future clinical approaches should integrate objective sleep testing with a psychologically informed framework to effectively diagnose and treat this challenging condition. Declarations Ethics Approval and Consent to Participate: Written informed consent was obtained from the patient for publication of this case report. Consent for Publication: Consent for publication was obtained. Competing Interests: The authors declare no competing interests. Patient Consent Statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying tables or clinical details. All identifying information has been removed to protect patient privacy. Funding: This work received no specific grant from any funding agency. Author Contribution MG and AW contributed to the conception, writing, and revision of the manuscript. Both authors read and approved the final manuscript. Acknowledgements: Not applicable. Data Availability Data sharing is not applicable as no datasets were generated or analyzed for this case report. References Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007, 3:7-10.10.5664/jcsm.26929. Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6:97–111. 10.1053/smrv.2002.0186 . Edinger JD, Krystal AD. Subtyping primary insomnia: is sleep-state misperception a distinct entity? Sleep Med Rev. 2003;7:203–14. 10.1053/smrv.2002.0253 . Rezaie L, Fobian AD, McCall WV, Khazaie H. Paradoxical insomnia and subjective-objective sleep discrepancy: A review. Sleep Med Rev. 2018;40:196–202. 10.1016/j.smrv.2018.01.002 . Feige B, Baglioni C, Spiegelhalder K, Hirscher V, Nissen C, Riemann D. The microstructure of sleep in primary insomnia: an overview and extension. Int J Psychophysiol. 2013;89:171–80. 10.1016/j.ijpsycho.2013.04.002 . Manconi M, Ferri R, Sagrada C, et al. Measuring the error in sleep estimation in normal subjects and in patients with insomnia. J Sleep Res. 2010;19:478–86. 10.1111/j.1365 2869.2010.00836.x . Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13:479–504. 10.5664/jcsm.6506 . Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540–5. 10.1093/sleep/14.6.540 . Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307. 10.1016/s1389-9457( . 00)00065 – 4. Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379(11):1129–41. 10.1016/S0140 . Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26:675–700. 10.1111/jsr.12594 . Perlis ML, Jungquist C, Smith MT, Posner D. Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. Springer Science & Business Media; 2006. Additional Declarations No competing interests reported. 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A subset of patients presents with paradoxical insomnia (also termed sleep-state misperception), defined by a striking mismatch between subjective complaints of severe sleeplessness and objective evidence of relatively normal sleep duration and architecture [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Emerging evidence suggests that paradoxical insomnia may involve altered sleep microstructure, hyperarousal, or neurocognitive abnormalities during sleep rather than a quantitative reduction in sleep time [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Comorbid psychiatric conditions, particularly anxiety and obsessive-compulsive traits, are common and may exacerbate the misperception. The diagnostic picture can be further complicated by comorbid sleep-disordered breathing, such as obstructive sleep apnea (OSA), a condition characterized by repeated episodes of partial or complete upper airway obstruction during sleep, quantified by the Apnea-Hypopnea Index (AHI), which measures the average number of apneas and hypopneas per hour of sleep [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Differentiating paradoxical insomnia from other insomnia subtypes is critical to avoid unnecessary pharmacologic interventions and to direct patients toward evidence-based behavioral treatments.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 37-year-old woman presented with severe, chronic insomnia, persistently reporting sleeping only \u0026ldquo;minutes per night.\u0026rdquo; Despite appearing alert and functional, she scored 2 on the Epworth Sleepiness Scale (ESS) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and 28 on the Insomnia Severity Index (ISI) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], indicating severe clinical insomnia. A two-night home sleep test revealed normal sleep architecture with mild OSA (Apnea\u0026ndash;Hypopnea Index [AHI]\u0026thinsp;=\u0026thinsp;5 events/hour), objectively confirming over 4.5 hours of sleep. Multiple pharmacological trials, including hypnotics, sedating antidepressants, benzodiazepines, and antipsychotics, provided no subjective improvement (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The patient maintained a fixed belief of sleeplessness despite contrary evidence. The ESS and ISI results are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEpworth Sleepiness Scale Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSituation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore (0\u0026ndash;3)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSitting and reading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatching television\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSitting inactive in a public place\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeing a passenger in a car for an hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLying down to rest in the afternoon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSitting and talking to someone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSitting quietly after lunch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStopped in traffic while driving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eNote: A score\u0026thinsp;\u0026le;\u0026thinsp;10 is considered normal.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInsomnia Severity Index Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISI Item\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore (0\u0026ndash;4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Severity of sleep onset difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Severity of sleep maintenance difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Severity of early morning awakening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Dissatisfaction with sleep pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Noticeability of impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Worry/Distress about sleep problem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Interference with daily functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eNote: Scores 22\u0026ndash;28 indicate severe clinical insomnia.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Previous Pharmacological Interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication Class\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecific Medication \u0026amp; Regimen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReported Outcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Benzodiazepine Hypnotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZolpidem 10 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective benefit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEszopiclone 2 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective benefit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSedating Antidepressants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrazodone up to 150 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e~\u0026thinsp;3 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinimal change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoxepin 10 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinimal change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMirtazapine 15 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e~\u0026thinsp;3 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo perceived sleep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzodiazepines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLorazepam 1\u0026ndash;2 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo benefit reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTemazepam 15 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo benefit reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuetiapine 25\u0026ndash;50 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOlanzapine 5 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisperidone 1 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 night\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLurasidone 20 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 night\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo subjective improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Sedatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHydroxyzine 50 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo reported sleep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGabapentin 300 mg nightly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 nights\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo reported sleep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInvestigations\u003c/h2\u003e \u003cp\u003eA two-night home sleep test was performed. The key objective findings and their clinical interpretation are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHome Sleep Test Results and Interpretation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep Latency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal sleep onset\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Sleep Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.49 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObjectively confirms substantial sleep duration (\u0026gt;\u0026thinsp;4 hours)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep Efficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood sleep continuity (normal\u0026thinsp;\u0026gt;\u0026thinsp;85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean SpO₂\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal oxygen saturation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLowest SpO₂\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo desaturation below 90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsence of significant hypoxemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApnea-Hypopnea Index (AHI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 events/hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeets criteria for mild Obstructive Sleep Apnea (OSA) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupine Sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndicates positional sleep but not predominantly supine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese findings objectively confirmed adequate sleep duration and architecture, with only mild, non-positional OSA present. When presented with the results, the patient expressed profound disbelief, insisting the device was inaccurate and maintaining she had been awake \u0026ldquo;all night.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDifferential Diagnosis\u003c/h3\u003e\n\u003cp\u003eThe clinical presentation prompted consideration of several diagnostic possibilities. The profound and persistent mismatch between the patient's subjective conviction of near-total sleeplessness and the objective evidence of normal sleep architecture and duration, coupled with refractoriness to multiple classes of sedating medications, was most consistent with a primary diagnosis of paradoxical insomnia. This perceptual disorder was likely exacerbated by anxiety-related hypervigilance and a somatic misperception, where quiet wakefulness or light sleep was misinterpreted as full wakefulness. An obsessive focus on sleep, characterized by intrusive ruminations about not sleeping, was a prominent perpetuating factor. While mild obstructive sleep apnea was objectively present, its severity (AHI\u0026thinsp;=\u0026thinsp;5) was insufficient to explain the degree of subjective distress or the reported complete lack of sleep, making it a comorbid condition rather than the primary etiology. A somatic delusional disorder was considered but deemed less likely due to the patient's preserved insight in other domains, absence of other psychotic features, and the primary emotional distress centered on the sleep complaint itself rather than a fixed, bizarre somatic belief.\u003c/p\u003e\n\u003ch3\u003eTreatment and Outcome\u003c/h3\u003e\n\u003cp\u003eGiven the failure of pharmacotherapy, treatment shifted to non-pharmacological intervention. A structured Cognitive-Behavioral Therapy for Insomnia (CBT-I) program was recommended, focusing on sleep restriction, stimulus control, cognitive restructuring, and relaxation training. Psychoeducation regarding paradoxical insomnia and the home sleep test results was provided repeatedly. Over six weeks of follow-up, the patient began to reluctantly reframe brief sleep episodes as \u0026ldquo;light rest,\u0026rdquo; though her core conviction of being awake most of the night persisted. Due to ongoing distress and limited insight, she was referred to a residential sleep-disorder behavioral program for intensive intervention.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case illustrates the diagnostic complexity that arises when paradoxical insomnia co-occurs with mild OSA. While the presence of mild OSA can sometimes explain or exacerbate sleep complaints, its clinical profile in this case was incongruent with the patient's extreme report of total sleeplessness. The core pathology aligned more closely with the hypervigilance, somatic focus, and catastrophic misinterpretation characteristic of paradoxical insomnia, as described in the literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This reinforces the principle that comorbid conditions must be carefully evaluated for their causal contribution to the primary complaint.\u003c/p\u003e \u003cp\u003eThe patient's complete lack of response to multiple drug classes, spanning traditional hypnotics to sedating antipsychotics, is a hallmark of paradoxical insomnia and underscores that it is generally refractory to standard hypnotic pharmacotherapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As medications that increase sleep drive do not correct the underlying perceptual distortion, this case powerfully reinforces the established guideline that first-line management for chronic insomnia, and particularly its paradoxical subtype, should be CBT-I, which directly targets the maladaptive thoughts and behaviors perpetuating the condition [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA significant clinical challenge encountered was the communication of objective sleep data. For the patient, being told she had \"slept several hours\" was perceived as invalidating and paradoxically increased her anxiety, a known risk that can lead to therapeutic rupture [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This experience highlights that clinicians must deliver such feedback with profound empathy and within a robust psychoeducational framework, normalizing the phenomenon of sleep-state misperception to foster engagement rather than defensiveness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case underscores several critical clinical lessons. First, paradoxical insomnia should be actively considered when a patient presents with severe subjective complaints that are strikingly disproportionate to objective sleep findings. Second, the presence of a mild comorbid condition such as OSA does not preclude a primary diagnosis of paradoxical insomnia and requires careful, nuanced clinical interpretation to avoid attributing the core complaint to an incidental finding. Third, pharmacotherapy alone is often ineffective for paradoxical insomnia, as medications do not correct the underlying perceptual distortion; therefore, first-line management should center on Cognitive-Behavioral Therapy for Insomnia (CBT-I) and targeted psychoeducation. Finally, communicating objective sleep results to the patient demands sensitivity and must be framed within a supportive therapeutic alliance to avoid invalidating the patient\u0026rsquo;s experience, which could otherwise lead to disengagement and therapeutic rupture.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case report highlights the critical importance of recognizing paradoxical insomnia, a condition defined by a profound subjective-objective sleep discrepancy. Accurate diagnosis is essential to avoid iatrogenic harm from escalating and ineffective pharmacotherapy and to steer patients toward evidence-based behavioral interventions. The co-occurrence of mild OSA adds a layer of diagnostic complexity but does not negate the primary perceptual pathology. The key message is that management must prioritize Cognitive- Behavioral Therapy for Insomnia and careful, empathetic psychoeducation over pharmacological strategies. Future clinical approaches should integrate objective sleep testing with a psychologically informed framework to effectively diagnose and treat this challenging condition.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e \u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication:\u003c/strong\u003e \u003cp\u003eConsent for publication was obtained.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting Interests:\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003ePatient Consent Statement:\u003c/h2\u003e \u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying tables or clinical details. All identifying information has been removed to protect patient privacy.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work received no specific grant from any funding agency.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMG and AW contributed to the conception, writing, and revision of the manuscript. Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData sharing is not applicable as no datasets were generated or analyzed for this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007, 3:7-10.10.5664/jcsm.26929.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhayon MM. 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Springer Science \u0026amp; Business Media; 2006.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Paradoxical insomnia, Sleep-state misperception, Obstructive sleep apnea, Insomnia, Cognitive-behavioral therapy for insomnia, Case report","lastPublishedDoi":"10.21203/rs.3.rs-8282876/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8282876/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eParadoxical insomnia (sleep-state misperception) is characterized by a marked discrepancy between self-reported poor sleep and objective polysomnographic evidence of normal sleep duration and architecture. We present a case of paradoxical insomnia comorbid with mild obstructive sleep apnea (OSA), highlighting diagnostic and therapeutic challenges. A 37-year-old woman presented with severe chronic insomnia, reporting sleeping only \u0026ldquo;minutes per night,\u0026rdquo; despite appearing alert and functional. A two-night home sleep test showed normal sleep latency (7 minutes), sleep efficiency (86.6%), and total sleep time (4.5 hours). Mild OSA was noted (AHI\u0026thinsp;=\u0026thinsp;5 events/hour) but was not considered causative of her distress. Multiple trials of hypnotics, antidepressants, benzodiazepines, and antipsychotics yielded no subjective improvement. The patient maintained a delusional-like conviction of sleeplessness despite objective evidence to the contrary. This case underscores the importance of recognizing paradoxical insomnia, particularly when complaints are disproportionate to objective findings and mild comorbid OSA is present. Management should prioritize cognitive-behavioral therapy for insomnia (CBT-I) and psychoeducation over pharmacologic escalation. Clinicians should communicate objective sleep data with empathy to avoid therapeutic rupture and promote engagement in behavioral interventions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Paradoxical Insomnia in the Presence of Mild Obstructive Sleep Apnea: A Case Report Illustrating Diagnostic Complexity and Treatment Challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 08:33:17","doi":"10.21203/rs.3.rs-8282876/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-20T04:07:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T15:12:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T15:06:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108025769973620004550728773852661920879","date":"2026-01-16T14:13:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22174404383561238315219693886468658547","date":"2026-01-16T14:04:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184248414236922824501795853839403114296","date":"2026-01-13T21:20:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-11T03:44:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247818928308752405943933461019851807403","date":"2026-01-08T22:24:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T12:03:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T11:22:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-12T14:07:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-10T18:44:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-12-10T18:39:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d9f0260-7dd9-4870-aac4-c3e6004a78c5","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T04:23:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 08:33:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8282876","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8282876","identity":"rs-8282876","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}